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HomeMy WebLinkAboutApp-Permit-ComplianceNo.,�y�-�0 •� ! beTK_3(D C©MMONAWALTH Of MASSACHUSETTS LOMP i' Board of Flerehly � �i�'IO t�" IMA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑ In Location' Owners Name l�E iN vV02P,45c�rt� Map/Parcel# 6 Address (4 t Lot# Telephone# Installer's Name its ti,� T u Desi ner'sName i g zCLI7 ° a1Cz 0 . Address FAddress Telephon e# Type of Building -F( I -L- .. Lot Size ,�?- VO QGZ" sq, ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other -Type of Building No. of persons Showers O, Cafeteria ( ) Other Fixuu'es Design Flow (min, required) 331D gpd Calculated design flow Design Bow provided 3q gpd Plan: Date " 1 D.Ui e( Number of sheets _ Revision Date Title Pe -&,)-p P -,Zi Description of Soil(s) _ Soil Evaluator Form No. rt Name of Soil Evaluator %A,, dist ,- TCS Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS -T'Ed.5 fl(-[ (.. f i (ag) 1 500 j CCw-) S &P -r u . -T``J V, The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree - to not lace the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date (q ' D �9 hrspections 1 �y-O^�� % .moi .tea r,�Cd� z�P� �✓an No. Y°.> 1(- - �" i-`.. ()t{tlq- FCL COMMONWF LTII OF MASSACHUSETTS Board of Health, �✓A410f)a"" IVIA. CERTIF'I'CATE OF COMPLIANCE Description of Work: Q Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ); Upgraded ',Abandoned ( ) by: f` c+ n u,, t fit,.,� ��1 �Itkr, . `#+ `7 'x 0 V <1-') t at "w @lsllt € r �xag' 4rvl' has been installed in accordance with the provisiotls of 310 CMR 1.5.00 (Tide 5) and the approved design plans/as-built plans relating to app lication No. fl --;Y n . 10 , dated +: rt i, l �ti� Approved Design Flow r79' (gpd) Installer 9 ,1 Desrgner a""„. -4,3C. Inspector. ^ I 1,4 ro ""' � ti �f? i � Date: ,+ The issuance of this'pei•mit shall not 'lie construed as aguarantee that the system mill function as designed. _. No. 1) 6 (, it ti t a.. CIA PE: COMMONWEALTH Of MASSACHUSETTS Board of Health, MA. DISPOSAL SYSTEM CONS RUCTIO PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system gg ri at 'c;-; Y o1 ` a ` ('a - 1 as described in the application for Disposal System Construction Permit No. ("',t -e , dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. `2 '�4 Form 1255 Rm 5196 A.M. Sorkin Co. Chdeom, MA Date 7 d e ,�'�Board of Health "� ...r